A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?

Choice A reason: Avoiding eye contact with a client experiencing auditory hallucinations may increase feelings of isolation or mistrust. Appropriate eye contact fosters therapeutic communication, conveying empathy and engagement. This action is not evidence-based for managing hallucinations, as it fails to address the client’s experience or build trust, making it inappropriate.
Choice B reason: Encouraging the client to lie down in a quiet room may reduce stimuli but does not directly address auditory hallucinations. This approach is more suitable for sensory overload or anxiety, not for engaging with or understanding the client’s hallucinations, which requires active communication to assess and manage symptoms effectively.
Choice C reason: Asking the client directly what they are hearing is a therapeutic approach that validates their experience and helps assess the nature and impact of hallucinations. This facilitates reality orientation, builds trust, and informs treatment, such as adjusting antipsychotics. It aligns with evidence-based care for schizophrenia, making it the correct action.
Choice D reason: Administering antianxiety medication immediately is not the first step for auditory hallucinations, which are primarily managed with antipsychotics. Without assessing the hallucinations’ content or severity, this action is premature and may not address the underlying psychotic symptoms, making it less appropriate than engaging the client directly.

Choice A reason: Decreasing fluid intake to firm stools is incorrect, as adequate hydration (2-3 L/day) is essential to prevent constipation, especially with opioids like oxycodone, which slow intestinal motility. Low fluid intake hardens stools, exacerbating constipation risk by reducing water content in the colon, indicating a misunderstanding of prevention strategies.
Choice B reason: Increasing dietary fiber intake (25-35 g/day) adds bulk to stools, stimulating peristalsis and counteracting opioid-induced slowed motility. Soluble and insoluble fiber, found in fruits, vegetables, and whole grains, promotes regular bowel movements. This statement reflects correct understanding of dietary measures to prevent constipation during opioid therapy.
Choice C reason: Taking a laxative only when constipated is reactive, not preventive. Opioids like oxycodone commonly cause constipation by reducing peristalsis via mu-opioid receptors in the gut. Prophylactic use of stool softeners or laxatives is recommended to maintain regular bowel movements, making this statement incorrect as it lacks a preventive approach.
Choice D reason: Exercising less to conserve energy worsens constipation, as physical activity stimulates intestinal motility, countering opioid-induced slowing. Regular movement, like walking, promotes bowel function by enhancing peristalsis and blood flow to the gut. This statement indicates a misunderstanding, as reduced activity increases constipation risk.